Provider Demographics
NPI:1578044889
Name:SKALKA, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:SKALKA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 BENNINGTON DR
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08055-9025
Mailing Address - Country:US
Mailing Address - Phone:609-457-3247
Mailing Address - Fax:
Practice Address - Street 1:622 EAGLE ROCK AVE # 102
Practice Address - Street 2:
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-2994
Practice Address - Country:US
Practice Address - Phone:973-669-0078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-24
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01814500225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty